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Detox Questionnaire

Name*

FirstLast

Email*

Date

Rate each of the following symptoms based on your typical health profile for the specified duration:*

Past month

Past week

Past 48 hours

0 – Never or almost never have the symptom
1 – Occasionally have it, effect is not severe
2 – Occasionally have it, effect is severe
3 – Frequently have it, effect is not severe
4 – Frequently have it, effect is severe

Head

Headaches

Faintness

Dizziness

Insomnia

Head - Total

EYES

Watery or itchy eyes

Swollen, red, or sticky eyelids

Bags or dark circles under eyes

Blurred or tunnel vision

Eyes - Total

EARS

Itchy ears

Earaches, ear infections

Ringing in ear, hearing loss

Drainage from ear

Ears - Total

NOSE

Stuffy nose

Sinus problems

Hay fever

Excessive mucous formation

Sneezing attacks

Total - Nose

MOUTH / THROAT

Chronic coughing

Gagging, frequent need to clear throat

Sore throat, hoarseness, loss of voice

Swollen or discoloured tongue, gums, lips

Canker sores

Total - MOUTH / THROAT

SKIN

Acne

Hives, rashes, dry skin

Hair loss

Flushing, hot flashes

Excessive sweating

Skin Total

HEART

Irregular or skipped heartbeat

Rapid or pounding heartbeat

Chest pain

Heart Total

LUNGS

Chest congestion

Asthma, bronchitis

Shortness of breath

Difficulty breathing

Lungs - Total

DIGESTIVE TRACT

Nausea, vomiting

Diarrhea

Constipation

Bloated feeling

Belching, passing gas

Heartburn

Intestinal/stomach pain

Total - DIGESTIVE TRACT

JOINTS / MUSCLES

Pain or aches in joints

Arthritis

Stiffness or limitation of movement

Feeling of weakness or tiredness

Pain or aches in muscles

Total - JOINTS / MUSCLES

WEIGHT

Binge eating/drinking

Craving certain foods

Excessive weight

Water retention

Underweight

Compulsive eating

Total - WEIGHT

ENERGY / ACTIVITY

Fatigue, sluggishness

Apathy, lethargy

Hyperactivity

Restlessness

Total - ENERGY / ACTIVITY

MIND

Poor memory

Confusion, poor comprehension

Difficulty making decisions

Stuttering or stammering

Slurred speech

Learning disabilities

Poor concentration

Poor physical coordination

Total - MIND

EMOTIONS

Mood swings

Anxiety, fear, nervousness

Anger, irritability, aggressiveness

Depression

EMOTIONS - Total

OTHER

Frequent illness

Frequent or urgent urination

Genital itch or discharge

OTHER - Total

XENOBIOTIC TOLERABILITY TEST (XTT)

1. Are you currently taking prescription drugs?*

No

Yes -1

Yes - 2

Yes - 3

Yes - 4

2. Are you presently taking one or more of the following over-the-counter

Cimetidine

Acetaminophen

Estradiol

3. If you have used or currently use prescription drugs, which of the following scenarios best represents your response to them?